Provider Demographics
NPI:1124149869
Name:MIELKE, HEATHER (DO)
Entity type:Individual
Prefix:
First Name:HEATHER
Middle Name:
Last Name:MIELKE
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 8792
Mailing Address - Street 2:
Mailing Address - City:BELFAST
Mailing Address - State:ME
Mailing Address - Zip Code:04915-8792
Mailing Address - Country:US
Mailing Address - Phone:440-238-7676
Mailing Address - Fax:440-816-5998
Practice Address - Street 1:18181 PEARL RD STE A104
Practice Address - Street 2:
Practice Address - City:STRONGSVILLE
Practice Address - State:OH
Practice Address - Zip Code:44136-6965
Practice Address - Country:US
Practice Address - Phone:440-238-7676
Practice Address - Fax:440-816-5998
Is Sole Proprietor?:No
Enumeration Date:2007-04-02
Last Update Date:2020-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101016706207Q00000X
390200000X
OH34-009351207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program